Monday, November 05, 2007

Pulling away from the school, I check the rear view for cars-- and for a glimpse of Joseph's face.

He's looking out the window-- his expression, a blank.

"Honey, so you'll probably have to wear braces-- but it won't be forever. Maybe a year or two-- tops."

"I really don't want braces, Mom."

"I know, Bud-- but if you need them, we gotta do it. Hey-- remember how that orthodontist we saw a couple of years ago told us you had a 'subtle underbite'? He thought you'd need to wear head gear, and then braces."

"Yeah, I know," Joseph says in a resigned tone.

"Well, he also said we could wait a while-- so listen, I'm going to ask this guy about the timing for all of this. And if we can wait a year, then I think we'll probably do that... but Honey, if this orthodontist says we need to do something soon, then you'll likely get braces this year."

Though I really hope we can wait. It's a lot of money...

Twenty minutes later, Joseph is lying back in a fully-reclined exam chair-- his new orthodontist bending over him.

I take a seat several feet away, and watch gloved fingers move swiftly over my son's teeth and jaw.

"Hmmm... " the orthodontist says, fingers still moving, "the spaces between his top front teeth have kept those teeth out in front of the lower ones."

"What?"

"You see, if we look at his profile, it's perfectly normal, nothing like, say, Jay Leno's-- but if we look at the rear molars, he definitely has an underbite. And a tricky one, at that."

Immediately, I'm out of my chair and peering into my son's mouth.

"Oh, yes-- have a look... right over here," the orthodontist says, pointing a gloved finger at Joseph's left rear molars.

"See how that second-to-the-last top molar is hitting the the last bottom molar? Well, it's not supposed to do that. And I'm afraid it's much more pronounced here than on the other side. This asymmetry is what makes it tricky."

"Oh."

"Let me show you with a model."

He walks over to his desk and picks up a pair of false teeth. Joseph climbs out of the exam chair and joins us, looking fascinated -- and a little nauseous -- as the orthodontist demonstrates how his bite is off, how his jaw is moving forward.

And how, over time, it will probably get a whole lot worse.

"All right then," I say, "what's the treatment plan-- and when can we start?"

"Now, Joseph is going to do a lot of growing over the next number of years, " the orthodontist begins slowly, "and because of this, we'll need to wait until he's done growing before trying to correct the issue."

"Excuse me?" I ask, staring at the man-- shocked.

"I'm sorry," he responds, an unmistakable note of sadness in his voice, "but you see, as Joseph grows, his lower jaw will likely continue to move forward... and well, trying to correct the misalignment before he's finished growing won't permanently correct the problem."

"And how do you correct the problem?"

"I'm afraid that he'll likely need surgery on his jaw-- at around age 20."

At first I don't say anything-- I can't.

Joseph steps away from the orthodontist's desk, goes to a corner of the room and sinks down onto several over-sized, stuffed animals lying there.

He leans back into soft fur, then turns his head away from us.

"Wait, wait- " I sputter, "the other orthodontist talked about head gear, about braces- I don't understand- "

"Head gear would be used to move the top jaw out-- Joseph doesn't have that issue. And braces won't affect the growth of his jaw. This is something that shows up in about 3 to 5 percent of the populationand- "

"Is there anything we can do now?"

"Well, we can take full x-rays to get a baseline-- so that we can monitor the issue- "

"But, is it possible that this won't be an issue-- that it won't get any worse?"

"Yes, that's possible," he responds, "but highly unlikely. It's more likely that the lower jaw will continue to grow forward-- more so when he goes through periods of rapid growth."

"I see."

Before leaving, we set up an appointment for x-rays in a few weeks-- and a follow-up consultation in January.

"No rush," the orthodontist tells the young woman who sets up these appointments.

No rush.

In the car, I tell Joseph that we'll do the follow-up, get a second opinion, and go from there.

"It's gonna be fine, Bud-- just fine."

After bringing him back to school, I try telling myself the same thing over and over.

But I'm furious.

Why does he have to worry about this, too?

I get home -- where Ryan is waiting -- and break down.

Then I go to the laptop, google "child with an underbite," and find out that this orthodontist's "wait-until-he's-done-growing-and-see" approach is the standard of care for this thing.

And then I see photos of older teens and adults who have waited and seen.

I also discover that the cost of the eventual corrective surgery is approximately $25,000-- and that insurance often doesn't cover it.

Damn it!

My son is dealt yet another blow-- and again, I'm helpless to stop it.

15 comments:

I'm not sure quite what else to say though, because every thought that comes to me about this ends up sounding like I'm giving a professional opinion. Of course, I'm not. I can't, I've never met Joseph and I'm a general dentist, not a specialist orthodontist.

Somehow though I wanted to share with you about the number of patients I've met who have been told the same possibility exists for them, only to have reached age of 20 (yes, the wait until growth has stopped is absolutely standard) and decide it isn't what they want to have done. Sure, many of these people have more prominent jaws than might be termed 'average', but if they can eat and speak (something that is more likely if the top teeth start out outside the bottom teeth) they choose to live with what they have. Googled photos won't necessarily be representative - remember that the photos that make it in to case reports, and on to the internet are often extremes.

I've met other patients who have chosen surgery and never regretted it for a second.

I guess what I want to say is that even though the chance of it not getting worse is small, this isn't quite the same kettle of fish as diabetes. There is a good chance that you'll get a degree of choice about what to do.

I wish there was something else I could offer, but take a ((((((hug))))))

Sounds like you found a good orthodontist even if his news is not great. Imagine if you'd done the other treatment, just to have it not work.I, too, am sorry that Joseph has to deal w/ this along with you. It's the pits.

You're absolutely right-- this news is nowhere near that diabetes "blow." (Thank God.)

But for an adolescent boy who wasn't liking the idea of braces, this was not easy to hear.

And though I wish you hadn't said the chance of it not getting worse is small, I was glad to read that this might not be as extreme as some of the photos I saw-- that he could simply end up with a prominent jaw.

(You see, the orthodontist made it sound like the need for surgery was inevitable.)

And yes, I'll take a hug. :-)

Nicole-

Though I'm not expecting much from the second opinion (Joseph's orthodontist came highly recommended) I'm starting to calm down about this.

There are definitely a lot worse things my son could (and does) have to deal with.

Just wish he didn't have another thing.

Jillian-

Thanks.

After that appointment, I had all of these scary images (courtesy of the orthodontist's "demo," the internet and my imagination) of what might happen over time. I also worried a good deal about what Joseph might be thinking.

But do you know what my son said last night when I mentioned his follow-up appointment?

"So I'll probably end up looking kind of like Matt Holliday... he looks cool."

(As a Red Sox fan, I wasn't too keen on hearing this; as his mom, more relieved than you'll ever know.)

Colleen-

I'm glad we found this guy, too.

It was weird though-- you see, whenever I've come across a kid with braces in our area, this orthodontist was the one who put them on.

That was part of the reason I was so shocked-- I just kept thinking: "He puts these things on all of these other kids-- why can't he do anything for my son?"

Oh Sandra - ugh. Sorry to hear about this. It certainly isn't something you want to hear coming from your orthodontist. I don't have any advice for you, as we've not been there. Our dentist has already pointed out that Dani has a nice overbite that will most likely need to be corrected in the years to come - but I believe braces will take care of that for her.

I am sorry to hear this, Sandra. As a person who has more than one chronic condition to deal with on top of Type I diabetes, I know personally how frustrating...no, how infuriating it is to deal with "one more thing." It ISN'T fair. We have more than enough on our plates.

I hope that Joseph's jaw doesn't worsen and that surgery, if it is in his future, is relatively minor.

I also read that while it's true that insurance doesn't cover the surgery if it's only for cosmetic reasons, they will often cover it if it's for non cosmetic reasons, such has having trouble eating or talking, etc. So...I know that's not exactly the same as saying it definitely won't happen, but maybe it's some comfort on the cost side of things - it seems like if Joseph really needs the surgery, it's likely it would be covered, and if he doesn't need it and he doesn't mind how he looks, then you don't have to worry about paying for it...

good luck! i know what it's like to have to worry about "just one more thing" on top of diabetes too...

The reason why this kind of problem is likely to get worse, not better, is because during the pubertal growth spurt mandibular (lower jaw) growth exceeds maxillary (upper jaw) growth. People in the opposite situation to Joseph, whose top teeth stick out a long way will therefore usually see the difference decrease and their problem reduce, while the reverse is more often true for kids like Joseph. But (there is always a but) notice that I said it is more likely to get worse, not better. It may equally well end up staying about the same. The point is probably more accurately put that it is very unlikely to get any better.

The thing I pick out from your description that sounds particularly positive is that it appears as though Joseph's upper teeth are currently outside his lowers (in dental jargon he does not have a reverse overjet). His orthodontist is obviously the best guide though.

If you have specific questions, or difficulty interpreting things you read or information you're given, please feel free to drop me an email.

Hugs to you guys; what distressing news! I really, truly hope an amenable solution can be reached that is okay to both you and Joseph.

(I have bad memories of orthodontic-related issues. First they cut a two-inch piece of skin from my mouth, right above my two front teeth; then I got the braces on. They they took them off. Then they put them back on. It was crazy...)

Ugh. Please tell Joseph I said that a) life is really unfair sometimes and he doesn't deserve one more piece of bad luck, and b)he really needs to come back and visit us again - Pepito has developed quite a good throwing arm!

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About Me

I'm a mom of two children-- a 9-year old girl and a 16-year old young man. In addition, I've been vice president of a marketing company; a full-time student (English major); a product services manager for a financial publisher; a childbirth instructor and birth assistant; an aspiring sculptor; and most recently, director of information services and outreach for a non-profit government watchdog group-- in exactly that order.